Incidence Of Prolonged Air Leak Research Articles

Implementation of an enhanced recovery protocol for lung volume reduction surgery: an observational cohort study.

Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP. This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS. Seventy-six LVRS patients were included (pre-ERP: n=41, ERP: n=35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P=0.0002), shorter chest tube duration (4 vs 12 days, P<0.0001) with a lower incidence of PAL (21% vs 61%, P=0.0005) and shorter LOS (6 vs 14 days, P<0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l). Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months.

Clinical effect of surgical treatment for lung metastasis and prognostic risk factor analysis: a single-centred cohort study.

This study aimed to compare the clinical effects of lobectomy and sublobar resection in the treatment of lung metastasis and to analyse the factors affecting patient prognosis. A retrospective analysis was performed on the clinical data of patients with pulmonary metastasis who underwent thoracic surgery at the Affiliated Cancer Hospital of Xinjiang Medical University between March 2010 and May 2021. A total of 165 patients who underwent pulmonary metastasectomy (PM) for lung metastasis met the inclusion criteria. Compared with the lobectomy group, the sublobar resection group had shorter operation time for pulmonary metastases (P < 0.001), lower intraoperative blood loss (P < 0.001), lower drainage volume on the first day after surgery (P < 0.001), lower incidence of prolonged air leak (P = 0.004), shorter drainage tube indwelling time (P = 0.002), and shorter postoperative hospital stay (P = 0.023). Multivariate analysis showed that sex (95% confidence interval (CI), 0.390-0.974; P = 0.038), disease-free interval (DFI) (95% CI, 1.082-2.842; P = 0.023), and postoperative adjuvant therapy (95% CI, 1.352-5.147; P = 0.004) were independent influencing factors of disease-free survival of patients who underwent PM. DFI (95% CI, 1.062-3.894; P = 0.032) and preoperative carcinoembryonic antigen (CEA) level (95% CI, 1.420-5.163; P = 0.002) were independent factors influencing the overall survival of patients in this group. Sublobar resection provides a safe and effective treatment option for patients with pulmonary metastasis on the premise of ensuring resection of lung metastasis R0 . Female sex, longer DFI, the use of postoperative adjuvant therapy and a lower preoperative CEA level were all favourable prognostic factors.

Clinical and Economic Burden Associated with Prolonged Air Leaks Among Patients Undergoing Thoracic Resection: A Retrospective Database Analysis.

Prophylactic use of lung sealants among patients undergoing thoracic resection has been reported for the management of intraoperative air leaks and is associated with a lower incidence of prolonged air leak (PAL) and a shorter length of stay (LOS). This study estimated the incremental economic and clinical burden of PAL among patients with lung sealants used during thoracic resection in the United States. This retrospective analysis examined hospital data (Premier Healthcare Database) for adults (age ≥18 years) with inpatient thoracic resection between October 2015 - March 2021 (first admission=index) and lung sealant used during their procedure. Follow-up extended through 90 days post-discharge. Patients were grouped by presence/absence of PAL (ie, diagnosis of post-procedural air leak or post-procedural pneumothorax with associated LOS exceeding 5 days). Outcomes included intensive care unit (ICU) days, total index hospital costs, all-cause 30-, 60-, and 90-day readmission, discharge status, and in-hospital mortality. Generalized linear models quantified associations between PAL and outcomes, accounting for hospital-level clustering, and patient, procedure, and hospital/provider characteristics. Among the 9727 patients included for study (51.0% female, 83.9% white, mean age 66 years), 12.5% had PAL, which was associated with significant incremental increases in ICU days (0.93 days, p<0.001) and total hospital cost ($11,119, p<0.001). PAL also decreased the likelihood of discharge to home (from 91.3% to 88.1%, p<0.001) and increased the risk of readmission within 30, 60, and 90 days by up to 34.0% (from 9.3% to 12.6%;11.7% to 15.4%;13.6% to 17.2%, respectively), all p<0.01. Absolute risk of mortality was low, but two times higher in patients with PAL versus those without PAL (2.4% vs 1.1%, p=0.001). This analysis demonstrates that despite the prophylactic use of lung sealants, PAL continues to put a burden on the healthcare system, highlighting an unmet need for improved sealant technology.

Using Continuous Flow Data to Predict the Course of Air Leaks After Lung Lobectomy.

Assessments of air leaks are usually performed subjectively, precluding the use of air leaks as an evaluation factor. We aimed to identify objective parameters as predictive factors for prolonged air leak (PAL) and air leak cessation (ALC) from air flow data produced by a digital drainage system. Flow data records of 352 patients who underwent lung lobectomy were reviewed, and flow data at designated intervals (1, 2, and 3 hours postoperatively [POH] and 3 times a day thereafter [06:00, 13:00, 19:00]) were extracted. ALC was defined by flow less than 20 mL/min over 12 hours, and PAL was defined as ALC after 5 days. Cumulative incidence curves were obtained using Kaplan-Meier estimates of time to ALC. Cox regression analysis was performed to determine the effects of variables on the rate of ALC. The incidence of PAL was 18.2% (64/352). Receiver operating characteristic curve analysis showed cut-off values of 180 mL/min for the flow at 3 POH and 73.3 mL/min for the flow on postoperative day 1; the sensitivity and specificity of these values were 88.9% and 82.5%, respectively. The rates of ALC by Kaplan-Meier analysis were 56.8% at 48 POH and 65.6% at 72 POH. Multivariate Cox regression analysis revealed that the flow at 3 POH (≤80 mL/min), operation time (≤220 minutes), and right middle lobectomy independently predicted ALC. Air flow measured by a digital drainage system is a useful predictor of PAL and ALC and may help optimize the hospital course.

Design Appropriate Incision Length for Uniportal Video-Assisted Thoracoscopic Lobectomy: Take into Account Safety and Minimal Invasiveness.

There is no criterion on the length of the uniportal video-assisted thoracoscopic surgery (UVATS) incision when performing lobectomy. We aimed to develop a nomogram to assist surgeons in designing incision length for different individuals. A cohort consisting of 290 patients were enrolled for nomogram development. Univariate and multivariate logistic regression analyses were performed to identify candidate variables among perioperative characteristics. C-index and calibration curves were utilized for evaluating the performance of the nomogram. Short-term outcomes of nomogram-predicted high-risk patients were compared between long incision group and conventional incision group. Of 290 patients, 150 cases (51.7%) were performed incision extension during the surgery. Age, tumor size, and tumor location were identified as candidate variables related with intraoperative incision extension and were incorporated into the nomogram. C-index of the nomogram was 0.75 (95% confidence interval: 0.6961-0.8064), indicating the good predictive performance. Calibration curves presented good consistency between the nomogram prediction and actual observation. Of high-risk patients identified by the nomogram, the long incision group (n = 47) presented shorter duration of operation (p = 0.03), lower incidence of total complications (p = 0.01), and lower incidence of prolonged air leak (p = 0.03) compared with the conventional incision group (n = 55). We developed a novel nomogram for predicting the risk of intraoperative incision extension when performing uniportal video-assisted thoracoscopic lobectomy. This model has the potential to assist clinicians in designing the incision length preoperatively to ensure both safety and minimal invasiveness.

Real-world perioperative outcomes of segmentectomy versus lobectomy for early-stage lung cancer: a propensity score-matched analysis.

This study aimed to compare the real-world outcomes of segmentectomy and lobectomy for lung cancer after adjusting for background factors and the extent of lymphadenectomy. This retrospective cohort study used a nationwide database in Japan. The data of patients with clinical stage 0/IA lung cancer who underwent segmentectomy or lobectomy between 2017 and 2019 were retrieved. Short-term postoperative outcomes were compared between the segmentectomy and lobectomy groups using propensity score-matched analysis. In the total cohort of 59 663 patients, 11 975 and 47 688 patients were in the segmentectomy and lobectomy groups, respectively. After propensity score matching, 8426 matched patients from each group were retrieved. All confounders including age, sex, comorbidities, smoking history, respiratory function, tumour size, clinical stage, affected lobe and extent of lymphadenectomy were appropriately adjusted. The overall complication rate and the cardiopulmonary complication rate were lower in the segmentectomy group than in the lobectomy group (8.5% vs 11.2%, P < 0.001 and 7.5% vs 10.3%, P < 0.001, respectively). The incidence of prolonged air leak was also lower after segmentectomy than after lobectomy (3.6% vs 5.3%). Surgical mortality, operative time and blood loss volume were comparable between the 2 groups. The postoperative complication rate was lower with segmentectomy than with lobectomy for early-stage lung cancer.

Thoracoscopic segmentectomy versus lobectomy: A propensity score–matched analysis

ObjectivesThe aim of this study is to compare the postoperative complications, perioperative course, and survival among patients from the multicentric Spanish Video-assisted Thoracic Surgery Group database who received video-assisted thoracic surgery lobectomy or video-assisted thoracic surgery anatomic segmentectomy. MethodsFrom December 2016 to March 2018, a total of 2250 patients were collected from 33 centers. Overall analysis (video-assisted thoracic surgery lobectomy = 2070; video-assisted thoracic surgery anatomic segmentectomy = 180) and propensity score–matched adjusted analysis (video-assisted thoracic surgery lobectomy = 97; video-assisted thoracic surgery anatomic segmentectomy = 97) were performed to compare postoperative results. Kaplan–Meier and competing risks method were used to compare survival. ResultsIn the overall analysis, video-assisted thoracic surgery anatomic segmentectomy showed a lower incidence of respiratory complications (relative risk, 0.56; confidence interval, 0.37-0.83; P = .002), lower postoperative prolonged air leak (relative risk, 0.42; 95% confidence interval, 0.23-0.78; P = .003), and shorter median postoperative stay (4.8 vs 6.2 days; P = .004) than video-assisted thoracic surgery lobectomy. After propensity score–matched analysis, prolonged air leak remained significantly lower in video-assisted thoracic surgery anatomic segmentectomy (relative risk, 0.33; 95% confidence interval, 0.12-0.89; P = .02). Kaplan–Meier and competing risk curves showed no differences during the 3-year follow-up (median follow-up in months: 24.4; interquartile range, 20.8-28.3) in terms of overall survival (hazard ratio, 0.73; 95% confidence interval, 0.45-1.7; P = .2), tumor progression–related mortality (subdistribution hazard ratio, 0.41; 95% confidence interval, 0.11-1.57; P = .2), and disease-free survival (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.35-1.51; P = .4) between groups. ConclusionsVideo-assisted thoracic surgery segmentectomy showed results similar to lobectomy in terms of postoperative outcomes and midterm survival. In addition, a lower incidence of prolonged air leak was found in patients who underwent video-assisted thoracic surgery anatomic segmentectomy.

A nomogram for preoperative prediction of prolonged air leak after pulmonary malignancy resection.

BackgroundProlonged air leak (PAL) is one of the most common postoperative complications after lung surgery. This study aimed to identify risk factors of PAL after lung resection and develop a preoperative predictive model to estimate its risk for individual patients.MethodsPatients with pulmonary malignancies or metastasis who underwent pulmonary resection between January 2014 and January 2018 were included. PAL was defined as an air leak more than 5 days after surgery, risk factors were analyzed. Forward stepwise multivariable logistic regression analysis was performed to identify independent risk factors, and a derived nomogram was built. Data from February 2018 to September 2018 were collected for internal validation.ResultsA total of 1,511 patients who met study criteria were enrolled in this study. The overall incidence of PAL was 9.07% (137/1,511). Age, percent forced expiratory volume in 1 second, surgical type, surgical approach and smoking history were included in the final model. A nomogram was developed according to the multivariable logistic regression results. The C-index of the predictive model was 0.70, and the internal validation value was 0.77. The goodness-of-fit test was non-significant for model development and internal validation.ConclusionsThe predictive model and derived nomogram achieved satisfied preoperative prediction of PAL. Using this nomogram, the risk for an individual patient can be estimated, and preventive measures can be applied to high-risk patients.

The Correlation Between Fissureless Technique and Prolonged Air Leak for Patients Undergoing Video-Assisted Right Upper Lobectomy.

We aimed to assess the clinical usefulness of the fissureless technique, which avoided dissection of the lung parenchyma over the pulmonary artery, in preventing prolonged air leak after video-assisted thoracic surgery right upper lobectomy (VATS RUL). Perioperative outcomes, including the frequency of prolonged air leak after fissureless technique or traditional fissure dissection technique, which dissected the lung parenchyma through the fissure, were compared in patients who underwent VATS RUL (n = 213) between January 2016 and March 2020. We adopted our fissural grade to evaluate the degree of fused fissure ranging from II (light incomplete fissure) to IV (severe incomplete fissure), which covered all fissural grades in 213 patients. Fifty-four and 159 patients underwent fissureless and traditional techniques, respectively. Significant differences in the incidence of prolonged air leak (p = 0.037), time to air leak cessation (p = 0.047), and duration of chest tube placement (p = 0.017) were observed between fissureless and traditional technique groups. On multivariable analysis, traditional technique (p = 0.005), and greater fissural grade (III vs II, p = 0.020; IV vs II, p = 0.001) were significantly associated with prolonged air leak. Fissureless technique during VATS RUL can be a superior alternative to the traditional technique to prevent prolonged air leak in treating incomplete fissures.

Thoracoscopic Pulmonary Segmentectomy With Collateral Ventilation Method

BackgroundDespite its popularity in recent years, segmentectomy still faces a challenge: the accurate delineation of the intersegmental plane, especially in complex segmentectomy. In this study, we describe a method using collateral ventilation to create an inflation-deflation line for video-assisted thoracoscopic surgery (VATS) segmentectomy and evaluated its efficacy in complex segmentectomy by comparing it with simple segmentectomy. MethodsEnrolled in the study were 264 patients who underwent VATS segmentectomy from January 2017 to September 2018. We classified the clarity of the inflation-deflation line into 4 grades, and the procedures of grade 3 or 4 were considered successful. Meanwhile, we performed a propensity score matching analysis to compare complex and simple segmentectomy. ResultsComplete resection with free margins was achieved in all patients. In inflation-deflation line clarity evaluation, 245 patients were classified as grade 4 (92.8%), 10 as grade 3 (3.8%), 8 as grade 2 (3.0%), and 1 as grade 1 (0.4%). Procedural success (grade 3 or 4) was achieved in 255 patients (96.6%). Prolonged air leak (>5 days) was observed in 11 patients (4.2%). Propensity matching generated 83 pairs of well-matched patients. The proportion of procedural success and the incidence of prolonged air leak (>5 days) were similar in both groups. However, compared with simple segmentectomy, complex segmentectomy was associated with a longer median operative time (159 versus 135 minutes; P < .001). ConclusionsCollateral ventilation method is simple, safe, and effective in VATS segmentectomy to identify the intersegmental plane, and also well-adapted for complex segmentectomy.

Influence of suction on prolonged air leak after VATS lobectomies: a prospective randomized study

Background. Prolonged air leak is the most common postoperative complication following lung resection. Despite the huge number of researches concerning this problem, no consensus exists regarding the choice of the appropriate method of pleural space drainage after thoracoscopic surgery.Objective. To compare suction and water-seal regarding their influence on the incidence of prolonged air leak.Material and Methods. This prospective randomized trial included sixty patients who underwent VATS lobectomies on different diagnoses in the Center for Thoracic Surgery, Clinical Hospital no. 122 (St. Petersburg) from September 2018 until May 2020. The open-label randomized controlled trial involved two groups: control group (water-seal drainage) and suction group. Each group consisted of thirty patients. Ten patients were discharged with a Heimlich valve.Results. The incidence of prolonged air leak was 23%. Patients in the suction group had a higher duration of air leak than those in the control group (5.3 ± 1.3 vs 3.7 ± 0.9 days, р = 0.04). The number of air leak cases was slightly higher in the suction group (8 and 6 patients); however, the difference was not significant (р = 0.57). Both groups had no difference in the number of complications (р = 0.2). There were no cases of reoperation.Discussion. The advantage of water-seal is a lower risk of parenchymal defects. Suction may increase holes in visceral pleura, cause hyperexudation, leading to prolonged duration of drainage. At the same time, the use of suction may decrease residual pleural spaces, match visceral and parietal pleura, which may decrease the duration of air leak. A lot of studies on this issue was performed, however, their results are contradictory.Conclusion. Drainage of pleural space after VATS lobectomies may be safely performed with water-seal. In the case of increasing surgical emphysema or appearance of progressive dyspnea, suction should be applied

Prolonged air leak after reoperative pulmonary resection (with prior ipsilateral chest surgery).

Reoperative pulmonary resection (with prior ipsilateral chest surgery) has been reported to be associated with a high rate of postoperative complications. The objective of this study was to evaluate prolonged air leak (PAL) after reoperative pulmonary resections. We conducted a single-centre retrospective analysis on 100 consecutive patients undergoing ipsilateral reoperative pulmonary resection at our institution between March 2012 and February 2020. We investigated the incidence of PAL after reoperative pulmonary resections in comparison to that after first operations and analysed potentially relevant factors of PAL after reoperations. After reoperations, the incidence of PAL was 24%. The incidence of PAL after reoperations was significantly higher than that after first operations (P < 0.01). On multivariable analysis, anatomical resection (P = 0.03) and thoracotomy approach (P = 0.02) were found to be significant factors associated with the occurrence of PAL, and age was a significant factor associated with chest tube duration (P < 0.01) and length of hospital stay (P < 0.01) after reoperative pulmonary resection. Our study identified significant risk factors of PAL after reoperative pulmonary resections, which would be an important step towards improved management of patients undergoing reoperative pulmonary resections.

Extensive Lung Resection for Nontuberculous Mycobacterial Lung Disease With Multilobar Lesions

Nontuberculous mycobacterial lung disease often spreads to multiple lobes, and extensive lung resection (ELR) is sometimes required to control the disease. The safety and feasibility of ELR for nontuberculous mycobacterial lung disease remain unclear, however. This retrospective study included patients with nontuberculous mycobacterial lung disease who underwent adjuvant lung resection. Characteristics were compared between patients who underwent ELR and those who underwent simple anatomic lung resection (SALR). The outcome data were analyzed by a Cox regression analysis. A total of 146 patients underwent ELR (n= 54) or SALR (n= 92). ELR was associated with a longer operative time (306 vs 237 minutes; P < .001) and higher incidence of prolonged air leak (17% vs 3.3%; P= .016) than SALR. Rates of mortality, sputum culture conversion (positive to negative), and microbiological recurrence did not differ markedly between the groups. In the multivariate analysis, ELR was not a significant risk factor for an unfavorable outcome after nontuberculous mycobacterial lung disease surgery (hazard ratio, 2.23; 95% confidence interval, 0.82-6.03; P= .11). ELR for nontuberculous mycobacterial lung disease has some drawbacks compared with SALR but seems as safe and feasible as SALR. ELR may provide improved disease control in some cases of nontuberculous mycobacterial lung disease with multilobar lesions.

Comparison of Short-term Outcomes of Lung Segmentectomy by Robotic-assisted and Video-assisted Thoracoscopic Surgery

背景与目的肺段切除术的开展越来越广泛，在现在的外科技术下，电视辅助胸腔镜手术（video-assisted thoracic surgery, VATS）是广泛采用的手术方式，同时机器人辅助胸腔镜手术（robot-assisted thoracic surgery, RATS）也提供了一种精准高效的手术方式，本研究旨在对比两种手术方式在肺段切除术中的短期效果。方法回顾性分析2016年1月-2017年4月在青岛大学附属医院胸外科行VATS及RATS肺段切除术的患者临床资料，比较两组患者基线数据及手术时间、术中失血量、淋巴结切除数、术后胸腔引流管带管天数、术后住院天数、术后房颤及肺部感染发生率等。结果共166例患者接受肺段切除术，两组均无中转开胸及围手术期死亡病例。其中VATS 85例，RATS 81例，术中淋巴结切除数在RATS组多于VATS组，差异具有统计学意义[（13.07±5.08）个vs（10.81±5.74）个，P=0.010）]，两组在手术时间、术中失血量、术后带管时间及住院时间无统计学差异（P > 0.05），术后的房颤、肺漏气（≥6 d）及术后肺炎发生率方面二组差异无统计学意义（P > 0.05）。结论相比于VATS，RATS具有相似的安全性及可操作性，淋巴结切除数目较VATS明显为多。

Safety and complications of medical thoracoscopy in the management of\xa0pleural diseases

BackgroundMedical thoracoscopy is considered an overall safe procedure, whereas numbers of studies focus on complications of diagnostic thoracoscopy and talc poudrage pleurodesis. We conduct this study to evaluate the safety of medical thoracoscopy in the management of pleural diseases and to compare complications in different therapeutic thoracoscopic procedures.MethodsA retrospective study was performed in 1926 patients, 662 of whom underwent medical thoracoscopy for diagnosis and 1264 of whom for therapeutic interventions of pleural diseases. Data on complications were obtained from the patients, notes on computer system, laboratory and radiographic findings. Chi-square test was performed to compare categorical variables and Fisher’s exact test was used for small samples.ResultsThe mean age was 51 ± 8.4 (range 21–86) years and 1117 (58%) were males. Diagnostic procedure was taken in 662 (34.4%) patients, whereas therapeutic procedure was taken in 1264 (65.6%) patients. Malignant histology was reported in 860 (44.6%) and 986 (51.2%) revealed benign pleural diseases. Eighty patients (4.2%) were not definitely diagnosed and they were considered as unidentified pleural effusion. One patient died during the creation of artificial pneumothorax, and the causes of death were supposed as air embolism or an inhibition of phrenic motoneurons and circulatory system. Complication of lung laceration was found in six patients (0.3%) and reexpansion pulmonary edema was observed in two patients (0.1%). Higher incidence of prolonged air leak was observed in bulla electrocoagulation group, in comparison with pleurodesis group. Moreover, pain and fever were the most frequently complications in pleurodesis group and cutaneous infection in entry site was the most frequently reported complication in pleural decortication of empyema group.ConclusionsMedical thoracoscopy is generally a safe and effective method, not only in the diagnosis of undiagnosed pleural effusions, but also in the management of pleural diseases. Mastering medical thoracoscopy well, improving patient management after the procedure and attempts to reduce the occurrence of post-procedural complications are the targets that physicians are supposed to achieve in the future.

Risk factors and outcomes of prolonged air leak after pulmonary resections.

Prolonged air leak (PAL) is a challenging complication in thoracic surgery. The aim of this study was to analyze the incidence, risk factors, and outcomes of PAL. We retrospectively analyzed 319 patients treated in a single center submitted to lobectomy, bilobectomy, segmentectomy, and wedge resections from January 2012 until August 2015. PAL was defined as air leak lasting more than 7days after surgery. The incidence of PAL was 14.7%. Bronchial obstruction (p < 0.05), low body mass index (BMI, p < 0.05), and hypoproteinemia (p < 0.001) were identified as independent preoperative risk factors of PAL. Intraoperative risk factors were lob- (p < 0.01) and bilobectomies (p < 0.05), pleural adhesions (p< 0.001), and length of stapler line (p < 0.001). Among the postoperative risk factors, we identified the use of active drainage (p < 0.01), the presence of subcutaneous emphysema (p < 0.001), massive air leak on the first postoperative day (POD 1, p < 0.001), and an incomplete re-expansion of the lung (p < 0.001). PAL was not associated with more complications in the postoperative period. One patient required reoperation due to a massive air leak. Twenty-six patients were discharged with a Heimlich valve with no complications and no need for re-admission. Bronchial obstruction, low BMI, hypoproteinemia, lob- and bilobectomies, pleural adhesions, length of stapler line, use of active drainage, the presence of subcutaneous emphysema, massive air leak on POD 1, and incomplete re-expansion of the lung were identified as independent risk factors of PAL. It had no influence on outcomes.

Videothoracoscopic lobectomy training in non-small cell lung cancer.

This study aims to evaluate the outcomes of video-assisted thoracoscopic surgery lobectomies performed by a training consultant or an experienced consultant. The study included 103 patients (81 males, 22 females; mean age 59.6±9.5 years; range, 32 to 84 years) who underwent video-assisted thoracoscopic surgery lobectomy due to non-small cell lung cancer. The training consultant assisted on the same side with the experienced consultant during the operations of the experienced consultant. The experienced consultant observed in the operating room and provided advice from a distance during the first five operations of the training consultant. Comorbidities, postoperative complications, and mortality were evaluated. Patients" demographic characteristics, comorbidities, and postoperative complications were similar between the two surgeons (p>0.05). Operative time, incidence of prolonged air leak, and length of hospital stay were higher in procedures performed by the training consultant (p<0.05). There were no significant differences in rates of life-threatening complications or mortality. Video-assisted thoracoscopic surgery lobectomy can be performed safely by surgeons in training. Effective training programs may produce outcomes comparable to those of experienced surgeons.

Fat-free mass index is superior to body mass index as a novel risk factor for prolonged air leak complicating video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer.

To evaluate whether fat-free mass index (FFMI) could be predictive of prolonged air leak (PAL) complicating video-assisted thoracoscopic (VATS) lobectomy for non-small-cell lung cancer (NSCLC). A retrospective study was conducted on the prospectively-maintained database in our institution between January 2015 and July 2017. The gender-specific median values of FFMI for males and females were applied as their respective cutoffs to stratify patients into low-FFMI group and high-FFMI group in initial univariable analyses. An effective multivariable logistic-regression analysis was then performed to demonstrate the predictive value of dichotomized FFMI. There were 1,091 surgical patients with NSCLC included (616 males and 475 females), with a PAL incidence of 14.6%. The median FFMI values among males and females were 17.3 and 14.6 kg/m2, respectively. PAL cases in both male (16.9±1.5 vs. 17.4±1.5 kg/m2; P=0.002) and female (14.0±0.9 vs. 14.6±1.1 kg/m2; P<0.001) groups had a significantly lower mean FFMI than that of non-PAL cases. The incidence of PAL was significantly increased in male patients with FFMI <17.3 kg/m2 (23.7% vs. 14.3%; P=0.003) and female patients with FFMI <14.6 kg/m2 (12.7% vs. 5.0%; P=0.003). Lower dichotomized FFMI was also significantly associated with prolonged time to air leak cessation and length of stay (LOS). Finally, multivariable logistic-regression analysis indicated that lower dichotomized FFMI [odds ratio (OR) =1.98; 95% confidence interval (CI): 1.33-2.96; P=0.001] could independently predict the occurrence of PAL. FFMI acts as an excellent categorical risk factor for PAL complicating VATS lobectomy and shows a much superior significance than body mass index (BMI) in terms of the prediction of PAL.

Invited correspondence on 'Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak?'

At the time I was initiating this study (1), I wasn’t aware of other studies on fissureless fissure-last technique. More precisely, as I start operating with this technique, especially for non-upper lobes, I was trying to solve a basic technical problem that I was facing from time to time, thinking I might have been the first to do so.

The effects of low suction on digital drainage devices after lobectomy using video-assisted thoracoscopic surgery: a randomized controlled trial†.

The optimal level of suction on digital chest drainage devices after lobectomy using video-assisted thoracoscopic surgery (VATS) is unknown and varies between thoracic centres. In this randomized controlled trial, we assessed the potential benefits of low suction of -2 cmH2O compared to -10 cmH2O, using a digital drainage device. Two hundred and twenty-eight patients were randomized into 2 groups after VATS lobectomy for suspected or confirmed lung cancer. Primary outcome was time to chest drain removal. Drain data were obtained from the digital drainage devices, and patient data were obtained from medical records during admission, with a follow-up until postoperative day 30. For the -2 cmH2O and -10 cmH2O groups, median (interquartile range) drainage duration was 27.4 h (23.3-71.2) and 47.5 h (24.5-117.8) (P = 0.047), and the incidence of prolonged air leak >5 days was 14.4% and 24.3% (P = 0.089), respectively. Median total fluid production was 566 h (329-1155) ml and 795 h (454-1605) ml (P = 0.007). Median time to consistent air leak cessation (<20 ml/min) was 5.2 h (0.3-34.2) and 23.7 h (0.8-90.8) (P < 0.001). There were no differences in the proportion or the size of the pneumothorax or subcutaneous emphysema after drain removal, and no differences were observed in postoperative morbidity. Median length of in-hospital stay was 2.0 days (2.0-5.8) and 3.0 days (2.0-9.0) (P = 0.18). A low suction level significantly shortened drainage duration, time to air leak cessation and total fluid production, without increasing morbidity. NCT02911259.